Expecting parents should decide before birth – here’s a look at the facts.

Expecting parents should decide before birth – here’s a look at the facts.

The birth of a son is a time of great joy. But it can be accompanied by anxiety and confusion for the new parents faced immediately with an urgent decision – should we have our son circumcised?

John S. Wiener, MD, chief of Duke Children’s Division of Urology, tells us what to think about.

-- Dennis Clements MD, PhD, MPH

Circumcision is the removal of the foreskin (or prepuce) that covers the head of the penis.

The practice has been around for over 10,000 years and is common to many cultures around the globe; however, circumcision of newborn boys was unique to Judaism until recently.

John S. Wiener, MD

A change began when medical experts in 19th century America and Britain first extolled the virtues of the infant circumcision. The arguments of the Victorian era medical literature almost seem comical today. Not only was circumcision touted to improve hygiene and prevent disease, it was reported to cure paralysis, epilepsy, and insanity. In an era of sexual repression, circumcision was widely (and mistakenly) accepted as a means to prevent masturbation.

Infant circumcision went from a practice to be avoided to a part of 33 percent of U.S. male births by 1930. As hospital births became more routine, the circumcision rate grew to over 90 percent in the 1970s.

A Look at the Evidence

Medical researchers looked at this trend and began to question the validity of the blind acceptance of circumcision.

A close look at the evidence (or lack thereof) led the American Academy of Pediatrics (AAP) to issue its first statement on the practice in 1975: “There is no absolute medical indication for routine circumcision of the newborn.”

In fact, no medical organization in the world recommends newborn circumcision because the risks of the procedure may not outweigh the risks to the infant. This led North Carolina and many other states to end Medicaid coverage for routine infant circumcision.

As a result, prevalence of circumcision in the U.S. today has declined to 31-79 percent, depending upon regional and ethnic variations.

How does this compare to the rest of the world? The rates vary widely from as high as 78 percent in South Korea to less than 4 percent in Britain and Denmark.

Pros and Cons

Although circumcision is becoming less common, research in the past 25 years has shown some clear benefits.

The AAP, accordingly, revised its most recent statement in 1999: “Existing scientific evidence demonstrates medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.”

What are these benefits and what are the data to back them up?

• Prevention of urinary tract infection. Circumcision reduces the incidence in infants boys by up to 10-fold, but it is only a reduction of 1 percent to 0.1 percent. The resulting benefit is not thought to continue at older ages.
• Prevention of penile cancer. Essentially only uncircumcised men develop this cancer but it is exceeding rare with only 1,500 new cases yearly in the U.S.
• Prevention of sexually transmitted diseases (STDs). Earlier reports of circumcision preventing common STDs such as gonorrhea and syphilis have not held up to scrutiny. Several recent reports from Africa have shown a 50 percent reduction in new HIV infections in adult men undergoing circumcision, but the relevance of this data to infant circumcision in the U.S. -- which has a much lower prevalence of HIV -- is unknown.
• Prevention of problems that may require circumcision at a later age. Little data exists of the need for circumcision at an older age due to infection beneath the foreskin (balanitis) or inability to retract the foreskin (phimosis), but the highest estimates are 10 percent.

Therefore, only a minority of males may actually benefit from newborn circumcision, and this must be weighted against the risks which include:

• Bleeding
• Local infection
• Injury to penis
• Poor cosmetic appearance due to too little or too much skin removed

Rarely, a child may require surgery in the operating room to manage such complications.
In addition, circumcision opponents point to studies demonstrating that circumcision diminishes sexual sensation in adulthood, but these findings have been challenged by other studies finding no difference in penile sensation in circumcised versus uncircumcised adults.

As with any surgical procedure, there is pain associated with circumcision. A local nerve block should be performed as part of the procedure to eliminate or reduce any associated discomfort.

Those unfamiliar with the uncircumcised penis are concerned about hygiene beneath the foreskin. The foreskin usually becomes free from the head and is able to be pulled back within a few years, allowing simple cleaning. Making this part of a boy’s bath or shower usually prevents any problems.

Time Is of the Essence

Why is the decision regarding circumcision an urgent one? The penis undergoes a growth spurt in the first few months of life and may quickly become too large to safely remove the foreskin. Hence, most practitioners limit the procedure to the first month of life. After that age, most recommend referral to a urologist to perform circumcision in the operating room under general anesthesia, incurring additional risks and significantly greater costs.

Parenthood is full of difficult decisions without clear answers. So, is circumcision necessary? The current evidence would appear to be an emphatic “no.” Is circumcision beneficial? Potentially.

Expecting parents should try to make a decision long before they reach the delivery suite. Additional advice can be obtained from your obstetrician, pediatrician, family doctor, or urologist.

-- John S. Wiener, MD, is chief of Duke Children’s Division of Urology.

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.